Question: Last night I had a 75 year old patient calling because he was SOB x 2 days with it worsening this evening. Patient could not sleep (could not breathe very well laying down) and was more SOB on exertion. I could hear fine crackles in the bases of his lungs. There was no ischemic chest pain or NTG history. His vitals on contact were HR 90, BP 188/70 (ish), SPO2 95% on Room air, 100% on NRB, RR 24 verified with an with ETCO2 of 40mmHg, No ST changes in 12 lead. He had some slight increased work of breathing on scene with mild increased diaphragmatic use but was speaking full sentences and in good spirits with us. Patient had a history of COPD and CHF. He also stated he had taken some of his Ventolin puffers prior to our arrival with no relief (probably made things worse). I wanted to treat him with NTG but he did not seem to be in enough distress initially, so I kept him on the NRB which he stated help initially. We got to the truck and started an IV enroute, then administered 0.8mg NTG. Literally… within about 2 minutes of the NTG admin, while I was patching, the patient had a sudden onset of severe SOB. We were right outside the hospital, so I grabbed my BVM, assisted his respirations distress until my partner could get us out of the truck and help me put CPAP on. CPAP helped and he was back to normal shortly after our transfer of care. My question is, should I have used the CPAP right away with the NTG, even though the patient was not showing signs of severe respiratory distress at the time, and on numerous auscultations of the lung, did not have any increase in crackles… until of course, he developed that sudden severe respiratory distress? My gut was to CPAP him early, but I felt he did not fit the protocol yet given his level of dyspnea, SPO2 sats, RR and minimal accessory muscle use.